Periodontal Conditions As Measured By CPITN In Sudanese

Adolescents And Adults In Two Cities In Sudan

 
This study examines the prevalence and severity of periodontal conditions and estimates the periodontal treatment needs by CPITN in groups of Sudanese subjects. Study sample was grouped according to age and a total of 264 subjects were examined, 126 adolescents and 138 adults. Results indicated that the prevalence of periodontal disease among adolescents was high, with 95.2% having pockets 4-5 mm and 4% having pocket depths ³ 6 mm. In the 35 to 44 years age-group, 71 % of the subjects had 4-5 mm pockets and 26% had pockets ³ 6 mm. Among the 45 to 64 years age-group, 64.5% had 4-5 mm pockets and 35.5% had pockets ³ 6 mm. All subjects in all age-groups needed oral hygiene instructions, and almost all required calculus removal for more than 5 sextants per subject. Complex (surgical) periodontal treatment was needed by 4% of adolescents to treat about 0.1 sextants per person, and by more than 30% of all adults to treat about 0.4 to 0.8 sextants per person.

 
The prevalence and severity of periodontal diseases are relatively high in Africans with marked variability between different geographical areas and socioeconomic groups.1 Periodontal disease is the most prevalent oral health problem in countries like Nigeria,2  Swaziland,3   Uganda4  and  Tanzania.5
Some African populations have severe periodontal disease even at an early age. A recent report on periodontal conditions in adolescents by a WHO team,6 Tanzania and Sierra Leone were classified among the countries with the highest level of severity.
In Sudan, Emslie7 reported high prevalence of periodontal disease which was closely associated with poor oral hygiene. Since then, the periodontal conditions have not been surveyed in any Sudanese population and, likewise, information on the prevalence and severity of periodontal disease and dental caries was scarce. Thus, a complete oral health examination of a population sample was carried out during the period January to March 1991.
This study describes the periodontal conditions and estimates the treatment needs of Sudanese adolescents and adults using the Community Periodontal Index of Treatment Needs (CPITN).8

 
Survey population

Samples were selected from areas inside and around the cities of Khartoum and El-Obeid. Population in these cities is considered a representative sample for the middle area of Sudan. Adolescents were selected from the final class of two intermediate schools of the two cities, 75 subjects from Khartoum and 51 from El-Obeid. Adults examined in Khartoum were 37 subjects from a farm and 39 from a local market, whereas in El-Obeid adults examined were 30 subjects from a bank and 32 from a local market. In each site, a list of available subjects was prepared and every second subject was then examined. Due to time limitation in the local markets, some subjects selected from two market sites were examined at their homes. A total sample of 264 individuals was examined, 126 adolescents and 138 adults.

Examinations

WHO Oral Health Assessment Form was used to record information on periodontal disease, dental caries and oral anomalies. Periodontal examination was performed with the WHO periodontal probe* in accordance with the recommendations for using the CPITN.8 For adults, index teeth examined were 17, 16, 11, 26, 27, 37, 36, 31, 46, 47; while for adolescents, index teeth were 16, 11, 26, 36, 31 and 46.10 Six sites were probed around each of the CPITN index teeth; mesiobuccal,            mesiolingual, distobuccal, distolingual, mid-buccal and mid-lingual. The higher score was recorded for each sextant according to the CPITN scoring system.8

Subjects were examined while seated on a straight chair with a tall back on which the head could rest. Daylight was used at all examination sites. All examinations were performed by one examiner, a qualified periodontist.

Data handling

The forms were submitted to the WHO/Oral Health Unit in Geneva where data were analyzed, tabulated and stored. In this study, samples were divided into three age-groups: 15 to 19 years, 35 to 44 years, and 45 to 64 years. The CPITN data were examined to determine the overall prevalence and severity of periodontal conditions among the three age-groups.

Periodontal conditions

Among the adolescents, 15 to 19-year age-group, 95.2% had probing pocket depths 4-5 mm and 4% had probing depths 6 mm or more [Fig. 1]. No subject was completely without symptoms of periodontal disease. Only 0.8% had bleeding on probing as their highest CPITN score calculated by sextant with a mean number of 3.4 sextants per individual had some degree of pocketing; 3.3 sextants per individual had pockets 4-5 mm while a mean number of 0.1 sextants had pockets 6 mm or more [Fig. 2]. A mean number of 0.1 sextants per individual was graded as healthy.
No individual in the adult age-groups (35 to 44 years and 45 to 64 years) was completely free from signs of periodontal disease [Fig. 1]. In age-group 35 to 44 years, 71.3% had 4-5 mm pockets and 25.7% had pocket depths 6 mm or more; only 3% had calculus as their highest CPITN score [Fig. 1 ]. In the oldest age-group, 64.5% had pocket depths 4-5 mm and 35.5% had pockets 6 mm or more
[Fig. 1].
Calculated by sextants, the age-group 35 to 44 years had a mean number of 4 sextants per individual with pockets, 3.6 of which had pockets 4-5 mm and 0.4 had pockets 6 mm or more [Fig. 2]. In the oldest age-group, a total of 5 sextants per subject had some degree of pocketing, 4.2 of which had pockets 4-5 mm and 0.8 had pocket depths 6 mm or more [Fig. 2].

Periodontal treatment needs

All subjects examined in this study needed oral hygiene instruction and motivation, classified as treatment need 1 (TN1) in the CPITN system. This indicates that no individual had a total absence of pockets and bleeding on probing.
Treatment need 2 (TN2) in the CPITN system includes a need for subgingival scaling in addition to oral hygiene instruction and motivation. Among the three age-groups, 99.2% of the adolescents and all adult subjects needed this type of treatment as shown in Table 1. The mean number of sextants per subject needing TN2 in each age-group were 5.3, 5.7 and 5.8, respectively (Tabie 1).
Treatment need 3 (TN3) means complex periodontal treatment and includes possible surgical treatment of pockets 6 mm or more in addition to TN2 type of treatment. A total of 4% adolescents, 25.7% of the middle age-group and 35.5% of 45 to 64-year age-group needed this treatment (Table 1). The mean number of sextants per subject needing TN3 type of treatment in each age-group were 0.1, 0.4 and 0.8, respectively (Table 1).

 
Oral health programs are presently planned for by many African countries. Such programs, when based on precollected data on different oral conditions, may facilitate the implementation of appropriate dental health services. In this respect, determination of the prevalence and severity of periodontal disease and dental caries in a population is mandatory. Information on the periodontal health status in the Sudan population is scarce. To date, except for the report of Emslie,7 there is a paucity in publication concerning the prevalence and severity of periodontal diseases in Sudan.
The CPITN is a practical approach for screening populations because of its simplicity which enables rapid assessment of individuals for periodontal conditions relative to treatment needs. In addition, the results of CPITN surveys from many countries around the world are now received, analyzed and stored at the Global Oral Data Bank (GODB) at the WHO Headquarters in Geneva6'9 as shown in Table 2 and Fig. 3. This permits the comparison to be done between different populations. Consequently, groups at higher or lower risks and possible social, economical and geographical factors that might affect the distribution and severity of periodontal conditions can be identified. Data for Sudan in the GODB was inadequate, hence, CPITN was used in this study to determine the prevalence and severity of periodontal conditions and, at the same time, to facilitate comparisons with other populations.
In this study, the prevalence of periodontal disease among adolescents was high, with 95.2% of the 15 to 19-year age-group having pockets 4-5 mm and 4% having pocket depths 6 mm or more. This situation is serious and alarming. Comparing the adolescents data on periodontal conditions stored at the GODB,6 few countries were classified as having more severe conditions than what has been observed in the present study [Fig. 3]. Poor oral hygiene may be a factor for this high prevalence and severity among investigated adolescents. Further analysis of our data may clarify this matter.
The age-group 35 to 44 years was considered as "Key group" by WHO because most population revealed signs of all oral diseases and various stages of periodontal conditions that could be investigated.10 Table 2 compares the prevalence and severity of periodontal conditions of the 35 to 44-year age-group {present data) with the data reported by WHO for populations from other countries having similar socioeconomic characteristics.9 The data indicated that our samples had the second highest prevalence and severity as compared with Bangladesh. In the oldest age-group of the present sample, 64.5% had pockets 4-5 mm and 35.5% had pockets 6 mm or more.
In his study, Emslie7 used the periodontal index11 (PI) to examine the severity and prevalence of periodontal diseases in Sudan but this does not allow for a direct comparison with theCPITN data of the present study although some trends may be seen. He found outthatthe mean PI scores were 1.4 for the 15 to 19-year age-group and 2.5 for the 30 to 39-year age-group. According to the PI scoring system, these scores indicate that most of the individuals in two age-groups only had chronic gingivitis and pocketing was not common. On the other hand, our data clearly indicated that most of the surveyed individuals in age-groups 15 to 19 and 35 to 44 years had different degrees of pocketing. This discrepancy may be due to differences in survey samples and study design, but it may also indicate a deterioration of the periodontal status of the Sudanese population during the last two decades.
In the present study, all subjects in all age-groups needed oral hygiene instructions, and almost all of them required calculus removal for more than 5 sextants per person. This reflects the poor level of oral hygiene and indicates the magnitude of the efforts required to overcome the situation. Additionally, complex periodontal treatment was needed by 4% of the adolescents to treat about 0.1 sextant per person and by more than 30% of all adults to treat about 0.4 to 0.8 sextant per person.
The results of this study may have implications for the periodontal health services in Sudan. The ultimate goal is to reduce the prevalence and severity of periodontal diseases. Nationwide preventive programs should be planned and implemented to improve the oral hygiene level. Since periodontal diseases are prevalent and severe even at an early age, preventive programs should be started among children at schools. However, subgroups at higher or lower risks should be identified so that the efforts can be concentrated on those groups. Further analysis of our data may identify the existence of such groups.